ESSENTIAL CERTIFICATE ‘A’ & ‘B’

Certificate granted to Mr./ Mrs./ Miss………………………….………………….…………………..……

Wife / Son / Daughter of Mr.……………………………………………….….……………………………
Employed in …………………………………………………………………….………………………..…

CERTIFICATE ‘A’
( To be completed in the case of Patients who are not admitted
to hospital for the treatment
1. Dr…..………………………………..…………………………………………here by certify :-
(a) that I charged and received Rs……………………………………………………………for
…………………………………………………………………………………. Consultations.
(b) that I Charged and received Rs………………………………………………………………...
for administering ……………………………………………………………….intravenous/
Intra-muscular /subcutaneous injection on…………………………………………………….
………………………………………………………..at my consulting room (dates to be
given the residence of the patients).
(c) that the injection admistered /were/were not immunizing or prophylactic purposes.
(d) that the patient has been under treatment at……………………………………………………
……………………………………………………..hospital my consulting room and that the
under mentioned medicines prescribed by me in connection were essential for the recovery/
prevention of serious deterioration in the condition of the patient.
The medicines do not include proprietary preparation for which cheaper substances of equal
therapeutic value for preparation which are primarily foods, toilets or disinfectants.
Name of medicine Price
1. ………………………………....................... ……………………..................
2. ………………………………....................... ……………………..................
3. ………………………………....................... ……………………..................
4. ………………………………....................... ……………………..................
5. ………………………………....................... ……………………..................
6. ………………………………....................... ……………………..................
(e) that the patient is/was suffering
from………………………………………..………………… and is/was under my treatment
from………………………………………………………...…
(f) that the patient is / was not given prenatal or postnatal treatment.
(g) that the X-Rays, Laboratory test, etc. for which and expenditure of Rs……………………….
was incurred was necessary and under taken on my advise at…………………………………
………………………………………………………….(Name of the hospital or laboratory).
 (2)

(h) that I reference the patient to Dr………………………………………………………………

………………………………………………………………………specialist consultation.
(i) that the patient did require/ required hospitalization.

Date…………………………… Signature & Designation

of Medical Officer and Hospital/
………………………………... Dispensary to which attached.

N.B. Certificate not applicants should be struck off.

Certificate (s) is compulsory and must be filled in by the Medical Officer in all cases.

NOTE 1. The above Certificate may be deemed to be regular receipts for the payment received by
the Medical Officer who will be required to affix a revenue stamp on the essentiality
receipts (Stamp where necessary would however be necessary from the specialists for
consultation with them, who do not sign the Essentiality Certificates.

NOTE 2. Where the receipts issued by the Government Hospital are not authorized forms (Printed
and numbered and the amount of these receipts is incorporated in the body or the
essentiality Certificates counter-signature of such receipts need not be insisted upon.